| ORDER FORM |
| Bald Eagle Assessments
and Training Materials |
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Please print clearly
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DATE: |
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ATTN: |
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AGENCY: |
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ADDRESS: |
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CITY/STATE: |
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ZIP: |
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PHONE # |
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| Prices
on this sheet are effective 1/1/2003 and replace all previously stated
prices................................ |
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Total |
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| Item Description |
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Quantity |
Price |
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Requested |
for Each |
Total |
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Package of |
10 |
$20.00 |
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$2.00 |
$0.00 |
| INDEPENDENT
SKILLS ASSESSMENT |
Package of |
25 |
$40.00 |
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$1.60 |
$0.00 |
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Package of |
50 |
$75.00 |
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$1.50 |
$0.00 |
| PERSONAL
STRENGTHS AND NEEDS |
Package of |
20 |
$10.00 |
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$0.50 |
$0.00 |
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Package of |
50 |
$20.00 |
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$0.40 |
$0.00 |
| ASSESSMENT
OF CLINICAL NURSING NEEDS |
Package of |
20 |
$10.00 |
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$0.50 |
$0.00 |
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Package of |
50 |
$20.00 |
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$0.40 |
$0.00 |
| ASSESSMENT
OF NUTRITIONAL NEEDS |
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Package of |
20 |
$10.00 |
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$0.50 |
$0.00 |
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Package of |
50 |
$20.00 |
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$0.40 |
$0.00 |
| SEXUALITY
ASSESSMENT GUIDE + 20 worksheets
+ 18 black & white line drawings in binder |
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$20.00 |
$0.00 |
| Worksheets
must be used with a copy of the guide above |
Package of |
20 |
$10.00 |
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$0.50 |
$0.00 |
| SEXUALITY
ASSESSMENT WORKSHEETS |
Package of |
50 |
$20.00 |
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$0.40 |
$0.00 |
| SEXUALITY
KIT - Includes : 10 Sexuality Assessments, Guide Book with
18 line drawings, |
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$200.00 |
$0.00 |
| anatomically
correct dolls, artificial penis, sanitary pads & condom assortment, soft
carry bag. |
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| Sample
copy of any (or all) assessments listed above ($5.00) indicate by name: |
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$5.00 |
$0.00 |
| Shipping Charges: |
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Minnesota
Exempt Tax # |
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Subtotal |
$ |
$0.00 |
| Orders up to $4.99 . . . |
add $1.00 |
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6.5% Tax Minn Only |
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| Order over $4.99 . . . . |
add 10% of subtotal cost |
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Shipping |
$ |
$0.00 |
| Orders
will be shipped fastest possible based on charges |
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TOTAL DUE |
$ |
$0.00 |
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It is requested that payment be included at the time of the order |
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SUBMIT ORDERS &
PAYMENT TO: |
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ATTN: |
Janet Baldus |
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| FOR OFFICE USE ONLY |
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Bald
Eagle Assessments |
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111 11th Ave. N. E. |
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| Received |
Processed |
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Austin, MN 55912 |
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| Billed |
Paid |
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www.baldeagle-assessments.com |
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Telephone inquiries: |
507-437-2074 |
| wab: 5/96 |
Shipped |
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E-Mail: |
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info@baldeagle-assessments.com. |
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